Progressive Clinical Reasoning throughout a DPT curriculum
Discuss the process of designing and implementing strategies to enhance opportunities for clinical reasoning within didactic and clinical education coursework from 1st to 3rd year. This session will provide examples of clinical reasoning throughout the entire curriculum as well as individual tools to foster reasoning.
Methods and/or Description of Project
Early learners tend to organize their knowledge in a more linear fashion, thereby limiting potential for direct links with more complex information and knowledge1. Expert or advanced learners tend to have a greater density of connections between facts, skills and concepts1. The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) illustrates the usage of the International Classification of Functioning, Disability and Health (ICF) model while capturing the complexities of patient-therapist interaction2. Synthesis of information, reflection, and application to clinical practice is a challenging and complex reasoning process that requires explicit development.
Initially within the curriculum, instructional methods incorporate the PT-CRT concepts in a more linear manner. In large part, cases focus on patient-therapist diagnostic and therapeutic reasoning which highlight typical attributes of the health condition, body structure/function, activities, and participation concerns. Guided self-reflection questions are utilized to illustrate the interactions within the reasoning process2.
As the student progresses, additional complexity is incorporated that involve patient-related environmental factors such as motivation, family support, beliefs and expectations. Guided self-reflection is advanced by the use of questioning that incorporates a focused and directed component and targets the interactions between the patient/client and their environmental factors. While this model has largely been successful in a didactic setting, the early learner often encounters a demand for a higher level of clinical reasoning during clinical experiences. This may be in part why the adoption of the ICF model has been slow in clinical practice3. There may be several reasons, but one consideration is that it does not fully account for the situational items encountered in the clinical reasoning process. The ICF model focuses on diagnostic and therapeutic reasoning, an essential component to physical therapy practice, however, it does not account for other factors outside the patient-provider relationship such as therapist-related and environmental factors. Situativite theory suggests that the situational context is crucial in the clinical reasoning process, and that the specific context will impact and influence the clinical reasoning of the provider4. Therapist-related factors may include motivation, emotion, well-being, stress, or job satisfaction. Louw et al5 reported that therapists currently experiencing low back pain believed that their pain was worse than their patient’s symptoms, which may potentially impact intervention selection. Environmental or practice factors may include appointment length, scheduling considerations, setting, payor source or staffing6. Higher level clinical reasoning is particularly challenging to an early learner that may have limited exposure to the therapist and environmental factors that are external to the patient-management schema. To enhance the clinical reasoning process of DPT students, an explicit thread was developed and integrated between courses of a single semester, across semesters and inclusive of part-time and full-time clinical education experiences.
DPT program faculty have targeted the process of building a framework for the clinical reasoning process in both didactic and clinical education course design. This scaffold builds in complexity as students progress through the curriculum. Initially, opportunities for early learners to begin linear, non-complex clinical reasoning by using the patient-therapist management model are weaved into foundational coursework. The foundational coursework ranges from examination skills to Integrated Clinical Education (ICE) where straight-forward cases surrounding patient management are utilized to foster early clinical reasoning skills. The ICE experiences are incorporated into 1st year didactic coursework and provide structured opportunities for the early learner to apply clinical reasoning concepts to actual patients, receive feedback and begin to realize other factors that relate to the reasoning process. Feedback processes surrounding ICE experience assignments further develop reasoning skills in the early learner. Interactive discussion groups following ICE experiences also foster meaningful reflection on the complexity of each patient/client interaction. Providing corrective feedback with recommendations for improvement has been shown to facilitate students’ success with development of appropriate clinical reasoning in the clinical environment7. This learning model lays the groundwork for expanding clinical decision-making skills within systems management and research courses, and full-time clinical experiences later in the curriculum. Learners have a concrete base knowledge of the connectivity within the ICF model from which to build thoughtful clinical decisions as complexity and expectation evolves throughout the curriculum.
Building upon the linear strategies, clinical reasoning processes in the 2nd year target the interactions between the patient and patient-related environmental factors such as family support, home layout, etc. Additionally, patient management models are developed by including more complex patient presentations and discussions regarding the impact of insurance coverage and psychosocial patient factors. Following the 2nd year of the curriculum, a full-time clinical experience allows the students to practice clinical reasoning with straight-forward and more complex patient presentations. Faculty and clinical instructors participate in guided self-reflection to enhance clinical reasoning. By the final year, the learner has developed clinical reasoning skills mostly centered in the patient management area. In the final didactic semester, the learner is now challenged by increased patient complexity in addition to considerations for therapist-related and external environmental factors6. Therapist-related factors may include their own beliefs, emotions, and motivation. External environmental factors include items such as setting, productivity standards, appointment length, co-payment and insurance restrictions. Terminal internships provide an extended time where the learner may continue to develop their reasoning strategies. Combined with a full-time internship, students participate in an online course that allow the students and faculty members to discuss patient-related, therapist-related and external environmental influences on their ability to provide optimal physical therapy interventions. During this course, students often share their experiences and provide peer feedback and suggestions. Faculty also provide some alternate considerations for the students to continue to develop their reasoning process while immersed in the clinical environment.
Conclusions/Relevance to the conference theme: The Pursuit of Excellence in Physical Therapy Education
Clinical reasoning development is a challenging component to teach within physical therapy education. Development of an explicit curricular thread for clinical reasoning has enhanced progression from early learner to entry-level clinician. Patient-related, therapist-related and external environmental factors are built upon throughout the curriculum.
1. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK. How Learning Works. CA: Jossey-Bass; 2010: 40-65
2. Atkinson HL and Nixon-Cave K. A Tool for Clinical Reasoning and Reflection Using the International Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model. Physical Therapy. 2011: 91(3): 416-430.
3. Escorpizo R, Stuck G, Cieza A, et al. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Physical Therapy. 2010; 90:1053-1063.
4. During SJ, Artino AR, Pangaro L, van der Vleuten C. Context and Clinical Reasoning: Understanding the perspective of the expert’s voice. Med Educ. 2011; 45:927-938.
5. Louw A, Puentedura EJ, Zimney K. A clinical contrast: physical therapists with low back pain treatment patients with low back pain. Physiotherapy Theory and Practice. 2015. 31(8): 562-7.
6. During SJ, Artino AR, Schuwirth L, van der Vleuten C. Clarifying Assumptions to Enhance Our Understanding and Assessment of Clinical Reasoning. Academic Medicine. 2013; 88:442-448.
7. De Beer M, Martensson L. Feedback on students’ clinical reasoning skills during fieldwork education. Australian Occupational Therapy Journal. 2015. 62(4): 255 – 264.
1. Define and outline clinical reasoning theory and strategies/models
i.e – ICF model, patient management model, PT-CRT, situative theory
2. Discuss research related to these theories and models
3. Discuss integration of clinical reasoning into a DPT curriculum
4. Discuss the progressive building of the clinical reasoning to include more reflection and discussion pertaining to situational context
5. Discuss methods of incorporating more structured clinical reasoning and self-reflection opportunities into clinical education
This educational session would be conducted using a lecture-based format including Powerpoint.
First segment: 0-30 minutes
Content overview, related research, relevance to PT education
Second segment: 30-60 minutes
Building of clinical reasoning within the didactic component of the curriculum, use of patient-management model, PT-CRT and situational context
Third segment: 60-90 minutes
Fostering clinical reasoning during full-time clinical experiences, qualitative outcomes surrounding clinical reasoning
Conclusion: 90 minutes to end